Medical Management of Achalasia Cardia
Medical management with pharmacologic agents (calcium channel blockers and nitrates) should only be used in patients who are not candidates for definitive interventions like pneumatic dilation, POEM, or surgery, as these medications are no longer considered first-line therapy due to limited efficacy. 1
Primary Treatment Approach
The management of achalasia cardia is fundamentally not medical but procedural, as all effective therapies aim to reduce lower esophageal sphincter pressure through mechanical disruption rather than pharmacologic means. 2, 1
Definitive Treatment Options (Not Medical Management)
For Type I and Type II achalasia, three equally effective options exist 2:
- POEM (per-oral endoscopic myotomy) - success rates >90% 3
- Laparoscopic Heller myotomy - 94% efficacy 1
- Pneumatic dilation - 85-93% symptom relief, though requires repeat dilations over time 2, 1
For Type III achalasia, POEM is the preferred treatment because it allows unlimited proximal extension of myotomy tailored to the extent of esophageal body spasm. 2
When Medical Management Is Appropriate
Calcium Channel Blockers and Nitrates
- Reserved exclusively for patients who cannot undergo pneumatic dilation or surgery 1
- Should be used only in patients not responding to botulinum toxin injections 1
- These medications were once used as initial treatment but are now relegated to last-line therapy due to poor efficacy 1
Botulinum Toxin Injection
- Reserved for patients who cannot undergo balloon dilation and are not surgical candidates 1
- May be administered via endoscopic ultrasound guidance in special circumstances (e.g., patients with esophageal varices where pneumatic dilation is contraindicated) 4
- Provides temporary relief but not durable long-term solution 5
Post-Procedural Medical Management
Proton Pump Inhibitor Therapy (The Only True "Medical Management")
After POEM, prescribe 8 weeks of proton pump inhibitor therapy to decrease acid secretion and aid mucosal healing. 6, 3
Key considerations for PPI therapy:
- Strongly consider pharmacologic acid suppression immediately post-POEM given increased risk of postprocedure reflux and esophagitis 6, 2
- Post-POEM patients are high risk for reflux esophagitis and may require potential indefinite PPI therapy 6
- Address gastroesophageal reflux prophylactically after any definitive treatment, especially POEM 6
Antibiotic Prophylaxis
- Single dose of antibiotics at time of POEM may be sufficient for prophylaxis 2
- Periprocedural antibiotics effective against enteric pathogens must be administered 3
Critical Clinical Pitfall
The most common error is attempting prolonged medical management with calcium channel blockers or nitrates as primary therapy. These medications have been superseded by procedural interventions that provide superior and more durable symptom relief. Medical management should be viewed as a temporizing measure only for patients with absolute contraindications to definitive therapy. 1